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Thursday, 19 February 2015

Book Review - A Scientist in Wonderland

Edzard Ernst initially came to prominence in the UK as Professor of Complementary Medicine, holding the first such chair anywhere in the world. That was in 1993, and Ernst, who already had a pedigree both as a clinician and a researcher, expected that his quest to rigorously apply the scientific method to the various fields of ‘complementary and alternative’ medicine would be welcomed by practitioners and adherents who would want to prove the efficacy of their different ‘modalities’. Now fast forward to 2015 and Ernst is in the public eye once more in the UK with the publication of ‘A Scientist in Wonderland’, his memoir that tells the story not just of his research findings, but also lays bare the meddling of Prince Charles, heir to the British throne and arch-proponent of homeopathy, detoxification theories and a raft of other ‘alternative therapies’.

The book describes Ernst’s circuitous route to that Professorship – from his unconventional upbringing in post-War Germany, his love of jazz and his hesitant move into medicine. This is an environment in which homeopathy and naturopathy are accepted to a greater extent than in the UK. Indeed his first posting is in Germany’s only homeopathic hospital, where patients seemed to respond well to the endlessly diluted concoctions which are homeopathic medicines. As he points out in graphic detail, there can be not a single molecule of active ingredient left in these medicines, but yet patients recovered. Evidence of effect? Or evidence of the natural evolution of many illnesses and the positive power of the placebo effect?

In time Ernst moves to more conventional medical institutions. In addition to growing clinical experience he also begins a research career, finding the role of scientist enormously rewarding and intellectually satisfying. His observes, wryly that:

An uncritical scientist is a contradiction in terms: if you meet one, chances are that you have encountered a charlatan. By contrast, a critical clinician is a true rarity, in my experience. If you meet one, chances are that you have found a good and responsible doctor.

There are certainly plenty of patients who will echo that, and indeed it is a complaint that many cancer patients will recognise. Indeed, many of us hope that the Medical Innovation Bill (aka the Saatchi Bill, which Ernst does not support), will encourage more of this critical and scientific thinking in our doctors.

In time Ernst becomes a Professor, first in Germany and then in the prestigious Vienna Medical School. But the administrative demands, the bureaucratic workload and the intensely political culture of in-fighting in Vienna takes its toll. And then, out of the blue, he sees an advertisement for a new post at the University of Exeter. He is intrigued by the position on offer and applies, and, eventually, he is offered the job. His clinical experience, including his experience in a homeopathic hospital, and his excellent research credentials make him the ideal candidate.

The research program he envisages is simple – he wants to systematically test a range of alternative treatments using the best tools available to medical science. In his mind this does not mean looking to see how often people use these treatments, how happy they are using them, how cheap they are and so on. He wants to test for efficacy using blinded, randomised, placebo-controlled trials. In other words he wants to treat these ‘alternatives’ as if they are real medicine. And of course the proponents of these treatments are horrified at the prospect.

Trials do take place, and the book includes a detailed description of the first of these, which investigated ‘spiritual healing’, but the results were uniformly the same. There is no evidence of efficacy, only evidence for a placebo effect. And, inevitably, these results drew the ire of the many proponents of these alternatives, including, finally, Prince Charles. As Ernst explains:

Slowly but surely I became resigned to the fact that, for some alternative medicine zealots, no amount of explanation would ever suffice. To them, alternative medicine seemed to have mutated into a religion, a cult whose central creed must be defended at all costs against the infidel.

In response to those who argue that if the effect is just down to the placebo, then subjecting the treatments to critical scrutiny will destroy that effect, the response from Ernst is clear:

The indisputable fact, however, is that recommendations to forgo effective mainstream medical treatments in favour of bogus cures and quackery does cost lives -- not just occasionally but regularly.

Ultimately there is a collision course between science and pseudoscience, and in this case this became personified, with Ernst on the one hand and the future King of England on the other. Where Ernst applies the scientific method and wants to see the evidence, Prince Charles is on an altogether different plain:

In his book Harmony: A New Way Of Looking At Our World, Prince Charles makes the claim, for instance, that “rivers flow just as our blood flows, by virtue of spirals”.

However, this memoir is more than a story of an uncompromising scientist ultimately forced out of his job by an equally uncompromising zealot committed to homeopathy and in a position of influence by virtue of his royalty. This is a staunch defence of science and the need to have an ethical position in medicine. In particular, chapter 6 (simply entitled Wonderland), takes apart the various arguments made by supporters of homeopathy and the like as to why their favoured treatments should not (or indeed cannot) be put to the test. It should be required reading for everyone interested in medicine – without exception.

And now, freed from the confines of his University post, Ernst has become an even bigger thorn in the side of Prince Charles and the peddlers of pseudoscience and wishful thinking. That this has come at some cost to him is of no doubt, but ultimately we benefit from his refusal to look the other way. The last word, then, belongs to him:

When science is abused, hijacked or distorted in order to serve political or ideological belief systems, ethical standards will inevitably slip. The resulting pseudoscience is a deceit perpetrated on the weak and the vulnerable. We owe it to our-selves, and to those who come after us, to stand up for the truth, no matter how much trouble this might bring.